The Takeaway: A Year of Living Trumpishly

As the 2017 congressional session staggers to a conclusion – capped off last night with only a short-term fix of partial funding of the Children’s Health Insurance Program and Community Health Centers coupled with a raid on the ACA Prevention Fund – let’s take a few minutes to consider what has happened during this first year of the Trump presidency, and what it suggests for health care policy and politics in the year ahead.

First, the agenda of governing Republicans is abundantly clear to anyone who is not deluding themselves. Their top priority is the further concentration of wealth at the very top of the income pyramid, accompanied by continuous undermining of the health and economic security of middle- and lower-income households. In health care policy terms, this has translated into an unrelenting assault on the Affordable Care Act (ACA) and Medicaid. (While Speaker Ryan continues to eye Medicare somewhat wistfully, cutting Medicare remains an aspirational goal, as even he seems to sense it would be politically suicidal – at least for now).

The health care assault has been both administrative and legislative. On the administrative front, the Trump administration has cut support for ACA marketplace enrollment, cancelled payments for cost- sharing reductions (CSRs), initiated the expanded sale of insurance plans that don’t meet ACA standards, and weakened consumer protections in marketplace plans in areas ranging from access to providers to overseeing rates and more.

With respect to Medicaid, Trump’s HHS department has clearly signaled its intent to approve state Medicaid waivers that would place financial and administrative barriers in the way of coverage. These barriers may include work requirements, increased cost sharing or other measures that will make it harder for people to enroll in Medicaid, keep their coverage or afford care when they need it.

On the legislative front, thanks to a massive organizing effort, repeated attempts to weaken the federal funding commitment to Medicaid, reduce ACA premium tax credits or strip away protections – like guaranteed issue, no pre-existing condition exclusions or limits on age rating – have failed. Unfortunately, the ACA’s individual mandate did not fare as well. After repeated failures to repeal the ACA outright, Republican leaders were finally able to achieve limited success by repealing this least popular aspect of the law – the individual mandate – to help them pay for all the goodies for special interests, their wealthy donors and pet issues for members in the $1.5 trillion deficit-increasing tax bill they were determined to jam through.

On the political front, we have seen that congressional Republicans are undeterred from their course of action despite the fact that both their ACA repeal bills and their tax cut bill have been wildly unpopular.

We have also seen that members appear not in the least troubled by their logical inconsistency in pursuit of their agenda. Two logic gaps have been particularly notable. First, Republicans denied that repealing the mandate would actually cause people to lose coverage, while still claiming that it would save money (apparently, the savings would appear by magic). In addition, even with the GOP assertions that mandate repeal would not have much effect, many were arguing at the same time that its removal would so destabilize the ACA that repeal would become inevitable.

Similarly congressional Republicans seemed to have no trouble simultaneously holding the view that we can afford $1.5 trillion in tax cuts that will disproportionately benefit the rich while at the same time asserting that we cannot afford health care for children, older adults, people with disabilities and low-income adults.

Looking Ahead to 2018

Early next year, advocates should expect initial GOP moves to set up the return of some variant of Graham-Cassidy in the form of a block grant that would combine funding from insurance tax credits and Medicaid expansion coupled with a financial restructuring of the pre-ACA Medicaid that would progressively short-change the program over time. As we saw this year, there will be an effort to move this agenda forward through the budget reconciliation process in order to bypass the need for any Democratic votes. At same time, advocates are going to have to address new state-level problems created by the combination of individual mandate repeal and expanded sale of short-term insurance.

But while it would be foolish not to expect and prepare for further assaults on health security in 2018, there are four reasons why we should enter into the coming debate with some optimism:

First and most importantly, we have beaten this agenda in the past. That proves it can be done. The lack of popular support for repeal, the strong support for Medicaid and the continued strong enrollment in the Exchanges despite Trump administration sabotage efforts are all positive signs for the future.

Second, by winning the Senate seat special election in Alabama, Democrats have cut the Republican margin to two in the chamber – leaving almost no margin for error in any repeal bill.

Third, it is an election year and that may make enacting big cuts in Medicaid and ACA tax credits an even harder lift in the House that it was this year.

Finally, taking on Medicaid is much tougher than repealing the individual mandate. More people than ever now like Medicaid. They don’t like the mandate. Undermining Medicaid affects tens of millions of people including not only beneficiaries, but also their families, their providers and many other sectors of the economy that depend on state funding and that would be adversely affected by state budget cuts if federal Medicaid funding were reduced.

However, optimism is not certainty. Winning is not self-executing. It will require every bit as much effort as it did in 2017. It will require an “all-of-the-above strategy” that deploys policy arguments, personal stories, grassroots mobilization and building alliances with multiple stakeholders, including many with whom there is only limited agreement. Even though the road to repeal is narrow, we cannot forget that repealing the ACA and cutting Medicaid is absolutely the default aspirational position of the large majority of the Republican caucus in both the House and the Senate. And, as we have just seen with the tax bill, the votes of Senators Collins, Murkowski and McCain cannot be taken for granted.

Winning next year will be challenging. We have done it before and we can do it again, but only if we are prepared to fight.